INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 24, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc., Monroe Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
|
Observations
Based on a physical plant inspection on August 24, 2022, the facility failed to light interior exits and stairs at all times as an emergency exit in the rear of the facility led to an unlit stairwell. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/30/2022, the director contacted the landlord responsible for building maintenance to advise of the lighting issue in the stairwell. An electrician is scheduled to come and correct the lighting issue by 09/30/2022. Facility director will check stairwell monthly during facility walkthrough to ensure all interior exits and stairs are lit at all times. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of fire drill logs from September 2021 through June 2022, the facility failed to ensure that a fire alarm or smoke detector was set off during any drill. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An additional smoke detector was purchased and installed on September 2, 2022 in an accessible location. Facility director or clinical supervisor will set off smoke detector during monthly fire drills as required and document it in the fire drill log. |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
|
Observations
Based on a review of seven client records, the facility failed to ensure that informed and voluntary consent to release information forms included the dated signature of a witness in one record reviewed.Client #6 was admitted on April 12, 2022 and was active at the time of the inspection. The record contained an informed and voluntary consent to release information form signed by the client on April 12, 2022, to the funding source that was missing the dated signature of a witness on the same date as the client.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will provide a re-training on proper completion of releases of information including dated signature of the witness on September 12, 2022. All new hires will complete confidentiality training which includes completion of consents in Relias. Staff will also check daily alerts for unsigned documentation to ensure releases are completed appropriately. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of six applicable records reviewed.Client #2 was admitted on July 16, 2021 and discharged on August 1, 2022. A treatment plan update was completed on February 17, 2022, and another treatment plan update was due to be completed by April 17, 2022; however, the next treatment plan update was not completed until May 19, 2022.Client #5 was admitted on February 7, 2022 and was active at the time of the inspection. The treatment and rehabilitation plan was completed on March 9, 2022 and a treatment plan update was due to be completed by May 9, 2022; however, the next treatment plan update was not completed until July 13, 2022.These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
Case trackers will be reviewed by clinical supervisor and implemented with all staff to utilize for caseload management on 9/12/2022. Case trackers will monitor attendance, treatment plan due dates, case consult due dates and ASAM updates. The caseload tracker will be reviewed for each counselor at weekly staff meeting. If clients are in need of a treatment plan update, there are staff designated before and/or during group sessions to be able to meet with the client to update the treatment plan as needed. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in five of seven applicable records reviewed.Client #2 was admitted on July 16, 2021 and discharged on August 1, 2022. Each treatment plan update completed since October 11, 2021 has indicated that the client was to receive weekly group sessions; however, the record contained no documentation of group sessions since October 18, 2021. Client #3 was admitted on October 13, 2021 and discharged on August 1, 2022. The individual treatment and rehabilitation plan completed on October 29, 2021 indicated that the client was to receive three group counseling sessions per week; however, the record contained no documentation of group sessions between November 5, 2021 and December 3, 2021.Client #5 was admitted on February 7, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on March 9, 2022, indicated that the client was to receive one individual counseling session per week; however, the record contained documentation of only nine sessions offered between March 9, 2022 and the date of the inspection. Client #6 was admitted on April 12, 2022 and was active at the time of the inspection. The treatment plan updates completed on June 15, 2022 and July 21, 2022 indicated that the client was to receive group counseling sessions weekly; however, the record contained no documentation of group sessions since June 28, 2022.Client #7 was admitted on March 25, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on April 11, 2022, indicated that the client was to receive one individual counseling session per week; however, the record contained no documentation of individual sessions between May 9, 2022 and June 3, 2022.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff will receive training from clinical supervisor on 9/12/2022 to review that treatment plans should match the level of care the client is receiving and should indicate the minimum requirement for that level of care. In order to maintain compliance with clients participating in treatment recommendations, case trackers will be reviewed and implemented on 9/12/2022. Case trackers will monitor attendance, treatment plan due dates, case consult due dates and ASAM updates. Each counselor's tracker will be reviewed during weekly staff meeting. Staffing has been made available to schedule individual sessions and update treatment plans as needed. |